The dermatologist leaned in close, his face just an inch away from his homeless patient's scalp, his fingers combing through her thinning hair, the better to see the "scaly bumps" she was complaining about.
"It bothers me; it's spreading, and I just want to know what it is," Ellen Ferrante, 59, told Dr. Ernesto Gonzalez.
As he inspected with a magnifying glass, Gonzalez told her it was folliculitis, and it was quite common. "You and I have to make a pact," he said. "If you feel the urge to scratch, instead take an ice cube and go like this." He made a motion of rubbing ice on his head. "That will relieve the itching, and with medication we'll prescribe, it should clear within 10 days."
It's a long way from his practice at Massachusetts General Hospital, where Gonzalez sees more well-heeled patients. The homeless sometimes can't, sometimes won't get to mainstream hospitals, so for nearly two decades, Gonzalez, 76, has taken his black bag to them at the Barbara McInnis House on Albany Street, where Boston Health Care for the Homeless Program (BHCHP) runs a treatment center.
Gonzalez doesn't do it for his resume: He's got pages of awards and "firsts." And at his age, recovering from a kidney transplant, it's not exactly convenient, or even medically advisable. But it's a calling he says he has heard since he was a kid growing up poor in Puerto Rico.
"My mother was a servant, and medicine is a service provider," he says.
One of his medical residents took such advice to heart. In 1985, Dr. Jim O'Connell cofounded BHCHP. "Ernesto was wildly interested from the beginning," says O'Connell, an internist who was a resident at Mass. General under Gonzalez.
"I was so used to being inside an academic hospital, and I thought I would be pushed to the fringes when I worked with the homeless," O'Connell says. "Ernesto was one of the first people to let me know that wasn't going to happen."
A little over a decade later, Gonzalez offered his own services to O'Connell's organization. The need was acute. Skin is the body's largest organ, and the homeless face a wide array of dermatological problems.
A nomadic existence with chronic exposure to weather, irregular personal hygiene, substance abuse, and unaddressed health and nutrition issues take a toll on the skin, and Gonzalez sees things on his homeless patients that he rarely sees at Mass. General: severe frostbite, ulcerated legs, florid tumors, trench foot, and infestations of lice, scabies, and bed bugs.
Then there's the other issue. That is, the homeless made to feel like "the other" sitting in a hospital waiting room.
"They're outcasts," says Gonzalez, a compact man who wears wire rim glasses and exudes a gentle authority. "Many doctors, nurses, and secretaries don't want to deal with them, as well as the executives they're sitting next to."
Like the 52-year-old woman — she looked years older — who was next to be examined by Gonzalez and medical resident Vladimir Ratushny.cq She wore jeans, was in a wheelchair, and spoke in a hoarse voice. "Everyone here's homeless, so you don't feel so bad," said the woman, who said her ex-husband threw her out of his apartment six months ago.
Again, Gonzalez leaned in with a magnifying glass, checking her neck and fingernails. He diagnosed psoriasis,cq reassured her that it was benign, and warned her that alcohol and certain medications can trigger it. "Usually, in two weeks, it will clear," he told her.
With his homeless patients, Gonzalez does not don a white coat or latex gloves except in the case of obvious infections. He wears a suit and tie, though he'll take off the jacket and roll up his sleeves. He feels it puts patients more at ease.
But no gloves? "In dermatology, whenever you wear gloves, you lose the dexterity of feel, and the palpability of skin is very important," he says. Ratushny did wear gloves and took notes as they examined patients.
A pioneer in many respects, Gonzalez was appointed chief of ambulatory dermatology services at Mass. General in 1977 and was the first Puerto Rican professor at Harvard Medical School in 1988. He made it his mission to diversify the medical staff "when they had no idea what diversity was," and it was his idea that the hospital offer interpretive services.
In 1986, he created several dermatology subspecialties, including a laser center for cosmetic surgery, where he was the first director. But after a decade, he decided it wasn't for him: "I think these are superficial, meaningless concerns."
Sometimes, he even tried to talk patients out of such cosmetic procedures.
"You can make a lot of money, but I didn't feel this was a calling for me," he said. He has stayed at Mass. General, but in 1998 began to volunteer with Boston Health Care for the Homeless, which he has continued to do one or two afternoons a month.
There is a direct path from Gonzalez's childhood in Aguadilla, Puerto Rico, to his work with the homeless. Before he was born, his mother was homeless. "We grew up very poor," he said. "We had no running water. My grandmother slept in the kitchen, my mother on a cot so me and my brother could sleep in the bedroom."
Both boys went to the University of Puerto Rico on scholarships, he in medicine, his brother in economics. Gonzalez came to Boston to finish his residency at Harvard Medical School and Mass. General, recruited by the hospital's and school's head of dermatology, Thomas B. Fitzpatrick.
"I came with a contract for two years," Gonzalez said. That was 39 years ago.
He became a pioneer in photochemotherapy at Mass. General, which was the first in the country to use the combination of light and medicinal compounds for skin disorders.
Gonzalez is also credited with pioneering telemedicine for underserved patients in the early 1990s: taking a photo or video of symptoms and e-mailing it to a dermatologist for a diagnosis and treatment plan. In fact, Gonzalez showed O'Connell and his team how to set up a system so they could send him photos for virtual diagnosis and treatment plans.
A grandfather of six, Gonzalez can't imagine retiring. But nearly two years ago, he was forced to cut back after he had a kidney transplant. He is working part time at MGH and his recent foray back into homeless medicine was his first since the transplant. He's hoping his doctors will release him for more such duties, but they worry about his exposure to infectious diseases since he is on immunosuppressants.
At any rate, Gonzalez has more or less cloned himself, establishing a clinical rotation for dermatology residents that includes a stint with the homeless. It began in 1998 when a resident, Jennifer Tan, asked whether she could accompany him to see those patients.
Besides having the chance to see less common maladies, the young doctors reap other professional benefits. "This is really the only place you can develop empathy," Gonzalez said. "It's not taught in medical school. I think it will make them better doctors, and people."
At McInnis House, Gonzalez was chatting with Ferrante about the scars on her scalp. "I fell down," she explained. She said she's recently moved back to Massachusetts after spending 12 years in Florida.
"I came here for better medical care," she told him. She'd been having chest pains and pneumonia and a biopsy revealed lung cancer. "At least I won't be lying on a park bench during chemo, sick as a dog," she said. She could stay at McInnis House during treatment.
They discussed the dilemma of being homeless and as she was leaving the examination room, Gonzalez put his hand on her shoulder and said: "Remember our agreement — no scratching!" Ferrante shook his hand and thanked him.
Bella English can be reached at firstname.lastname@example.org.